Proton beam radiosurgery for vestibular schwannoma: tumor control and cranial nerve toxicity

OBJECTIVE: We sought to determine the tumor control rate and cranial nerve function outcomes in patients with vestibular schwannomas who were treated with proton beam stereotactic radiosurgery. METHODS: Between November 1992 and August 2000, 88 patients with vestibular schwannomas were treated at the Harvard Cyclotron Laboratory with proton beam stereotactic radiosurgery in which two to four convergent fixed beams of 160-MeV protons were applied. The median transverse diameter was 16 mm (range, 2.5-35 mm), and the median tumor volume was 1.4 cm(3) (range, 0.1-15.9 cm(3)). Surgical resection had been performed previously in 15 patients (17%). Facial nerve function (House-Brackmann Grade 1) and trigeminal nerve function were normal in 79 patients (89.8%). Eight patients (9%) had good or excellent hearing (Gardner-Robertson [GR] Grade 1), and 13 patients (15%) had serviceable hearing (GR Grade 2). A median dose of 12 cobalt Gray equivalents (range, 10-18 cobalt Gray equivalents) was prescribed to the 70 to 108% isodose lines (median, 70%). The median follow-up period was 38.7 months (range, 12-102.6 mo). RESULTS: The actuarial 2- and 5-year tumor control rates were 95.3% (95% confidence interval [CI], 90.9-99.9%) and 93.6% (95% CI, 88.3-99.3%). Salvage radiosurgery was performed in one patient 32.5 months after treatment, and a craniotomy was required 19.1 months after treatment in another patient with hemorrhage in the vicinity of a stable tumor. Three patients (3.4%) underwent shunting for hydrocephalus, and a subsequent partial resection was performed in one of these patients. The actuarial 5-year cumulative radiological reduction rate was 94.7% (95% CI, 81.2-98.3%). Of the 21 patients (24%) with functional hearing (GR Grade 1 or 2), 7 (33.3%) retained serviceable hearing ability (GR Grade 2). Actuarial 5-year normal facial and trigeminal nerve function preservation rates were 91.1% (95% CI, 85-97.6%) and 89.4% (95% CI, 82-96.7%). Univariate analysis revealed that prescribed dose (P = 0.005), maximum dose (P = 0.006), and the inhomogeneity coefficient (P = 0.03) were associated with a significant risk of long-term facial neuropathy. No other cranial nerve deficits or cancer relapses were observed. CONCLUSION: Proton beam stereotactic radiosurgery has been shown to be an effective means of tumor control. A high radiological response rate was observed. Excellent facial and trigeminal nerve function preservation rates were achieved. A reduced prescribed dose is associated with a significant decrease in facial neuropathy.     

Programme planning and screening strategy in retinopathy of prematurity

Retinopathy of Prematurity (ROP) is one of the major emerging causes of childhood blindness. A well organised screening strategy and timely intervention can to a large extent prevent blindness due to ROP. This communication proposes a screening strategy and management plan to develop a model for the care of babies with ROP.     

Laser conjunctivoplasty: a new technique for correction of mild medial ectropion

Thirty patients with mild medial ectropion of the lower lid were treated by Argon green laser. A diamond-shaped area (6 x 4 mm in size) on the medial part of the tarsal conjunctiva of the lower lid was burnt with overlapping spots until white blanching and visible contraction of tissue were seen. The apex of the diamond was kept 4 mm below the punctal opening. After an average follow-up of 6 months, functional success was achieved in 22/30 eyes. Anatomical success in terms of repositioning of the punctum was attained in 24/30 eyes. The only side effect noted was a mild burning sensation of the eyes lasting for two hours after the procedure. This is the authors' initial experience with a somewhat new and easy procedure to treat mild medial ectropion of the lower lid that can be performed on an outpatient basis.     

Selective delivery of herpes virus vectors to experimental brain tumors using RMP-7

RMP-7, a bradykinin analog, has been shown to selectively open the blood-tumor barrier for the delivery of chemotherapeutic drugs to brain tumors. In contrast to bradykinin, RMP-7 has no hypotensive effects and has been approved for human use. This study was initiated to determine whether RMP-7 would open the blood-tumor barrier to virus vectors encoding tumor-killing genes in an experimental model. The herpes virus vector used, hrR3, which encodes virus thymidine kinase gene and the lacZ reporter gene, is defective in a gene encoding ribonucleotide reductase, replicates selectively in dividing tumor cells and not in postmitotic neural cells. It was determined that an optimum dose of RMP-7 (1.5-3.0 microg/kg over 10-15 minutes) enhanced viral delivery to brain tumors in rats bearing intracranial 9 L gliosarcomas when infused through the carotid artery immediately prior to virus vector application. Maximum expression of the lacZ reporter gene occurred at 3 days after intracarotid infusion. By 8 days, transgene expression was largely confined to tumor foci away from the main tumor mass. Viral delivery was essentially specific to tumor cells, with little transgene expression elsewhere in the brain. Minimal uptake and pathology was noted in the kidney, spleen, and liver. These findings indicate that intracarotid delivery of RMP-7 can augment the selective delivery of virus vectors to brain tumors in an experimental rat model, with the potential for application to human brain tumors.     

Percutaneous drainage access: a simplified coaxial technique

We describe an access technique that we have used in 150 nephrostomy and biliary drainage procedures and for access to some abscesses and viscera. The system provides safe coaxial access with a 22-gauge removable hub needle, which then acts as a guide wire and is replaced by an 18-gauge cannula. A major advantage is that only one guide wire is used (0.038-inch) for the entire drainage procedure. No significant complications have occurred to date with this method.     

State of emergency medicine in Azerbaijan

Background

There has been no previous study into the state of emergency medicine in Azerbaijan. As a legacy of the Soviet Semashko system, the “specialty” model of emergency medicine and integrated emergency departments do not exist here. Instead, pre-hospital emergency care is delivered by ambulance physicians and in-hospital care by individual departments, often in specialty hospitals. Emergency care is therefore fragmented, highly specialized and inefficient.

Aims

The Emergency Medicine Development Initiative (EMDI) of the International Medical Corps (IMC) was designed to improve the quality of emergency care in four pilot regional centers in Azerbaijan. The objective of this study was to assess the baseline emergency medical capacity of these four centers.

Methods

EMDI staff conducted a four-part baseline survey in April 2006 to assess emergency care in Ganja (the second largest city in Azerbaijan), Kurdamir, Shamkir and Yevlakh. Data collection involved interviews with relevant personnel and a retrospective records review in each city.

Results

Pre-hospital: The number of ambulance teams per 10,000 inhabitants is below the number required by local regulations. On average, 45% of 27 medications and 37% of 17 pieces of critical equipment were available. Of the emergency procedures, 21% could be performed in the pre-hospital setting. In-hospital: Admission rates were near 100% for the admissions department–an area that is supposed to function as an emergency department would. On average 57% of 40 medications and 42% of 22 pieces of critical equipment were available. Of the emergency procedures, 62% could be performed in the in-hospital setting.

Conclusions

The emergency medical system surveyed in Azerbaijan is inefficiently organized, under-financed, poorly equipped and lacks adequately trained staff. Reforms need to be directed towards achieving international standards, while adapting new models for service delivery into the existing framework and improving system capacity as highlighted by this baseline assessment.     

The disposal of used sharps by diabetic patients living at home

The disposal of sharps generated in the community has been identified as an area of public health and environmental health concern. While there is a large amount of literature on sharps disposal practices in healthcare settings, the sharps disposal practices of diabetic patients living at home has been poorly documented. This study describes the sharps disposal practices of diabetic patients in South Staffordshire, an English health district. A randomly selected sample of 1,348 adult (aged >or= 16 years) diabetic patients were obtained from the district population-based diabetes register. A self-administered questionnaire was posted to the sample. Non-responders received up to two reminders. A response rate of 91% was achieved. Household containers were used by: 34.1% of respondents for syringes; 35.1% for lancets; and 27.6% for needles. Sharps boxes were the least used method of sharps disposal. Many respondents indicated that they had received only verbal information on how to dispose of their sharps. Those who recalled receiving information were more likely to dispose of their sharps safely. The results of this study suggest that sharps are disposed of in the most convenient manner, into the household waste. This contributes to environmental pollution and places people at risk of physical and psychological trauma.     

Lipoma of Columella with septal extension in Pai syndrome: report of a rare case

Background

Lipoma in nasal region in a case of Pai syndrome is very rare. Very few cases of Pai syndrome with columellar lipoma with extension to septum and tip have been reported till date.

Case presentation

We report a very rare form of nasal lipoma in a case of Pai syndrome with extension to septum and tip in a 4 year old female child.

Conclusions

Pai syndrome with columellar lipoma with septal and tip extension should always be kept in mind when evaluating a swelling in the region of nasal tip, collumella and septum with notch in upper lip and corpus callosal lipoma.

     

An inexpensive ex-vivo porcine laparoscopic Nissen fundoplication training model.

BACKGROUND: We recently implemented the use of an ex-vivo porcine model to teach residents the fundamentals of performing a laparoscopic Nissen fundoplication. METHODS: Residents were trained using intact porcine esophagus, stomach, and spleen placed in a standard video-trainer. They were later asked to complete a survey containing a course evaluation. RESULTS: Sixteen residents (R1-R4) completed the survey. They agreed that (1) the exercise was a valuable use of their limited time, (2) repeating the exercise will be of additional benefit, (3) it will improve their ability to perform or assist in an actual case in the OR, and (4) the surgical principles learned using the model will transfer to other laparoscopic cases. Significant subjective improvements were reported in resident comfort level in assisting in or performing a laparoscopic Nissen fundoplication. CONCLUSIONS: The use of an inexpensive ex-vivo porcine training model increases resident comfort level in performing a Nissen fundoplication in the operating room.